Developing a local guideline for the management of cow’s milk protein intolerance

1. Developing a local guideline for the management of cow’s milk protein intolerance GP Study day 9th June 2010

2. Overview • Why develop a local guideline? • Diagnosis of CMPA • Symptoms of CMPA • Managing CMPA in primary care • Managing CMPA in secondary care • Controversies in guideline development • Discussion

3. Why develop a local guideline • No widely accepted, national guidelines • Significant problem (2-3% babies) • Some confusion (eg with lactose intolerance) • Wide variety in current practice • Often crosses professional boundaries • Better evidence base than for many other treatments that are currently recommended eg for “colick”

4. Diagnosing CMPA • Can be a challenge • Symptoms often non-specific, • difficult to quantify objectively • Symptoms: • should be consistent and related to feeds • typically within first month of life or within 1 week of switching to formula feed • Often affect more than one body system • History/family history of atopy increase likelihood but not diagnostic

5. Physiology • IgE mediated (SPT/RAST) Urticaria, swelling, wheezing, vomiting, anaphylactic symptoms Immediate Can be life threatening • Non IgE mediated – at least 50% (no tests available) Gut or skin symptoms more likely Delayed Is there a role for allergy tests?

6. Symptoms of CMPA

7. Diagnosing CMPA in primary care • Red flags? • Positive history • Exclusion diet for 2 – 4 weeks • Bottle-fed : extensively hydrolysed formula • Breast fed : maternal diary free diet (with calcium supps) • Rechallenge with CMPA after 4 weeks • No role for “allergy tests”

8. Management of CMPA in primary care • Proven when symptoms resolve on CMP-free diet and recur on challenge. • Restart CMP-free diet for 6 months or until aged 1 year (whichever later). • Refer to paed dietitians for weaning advice • Rechallenge with CMP at 12 months of age and every 6 months until passes or aged 3 • Refer to paeds if persistent symptoms aged 3yrs

9. Management of CMPA in secondary care • Likely to be more severe cases – eg faltering growth, blood in stools, severe reflux • Includes those not responding to primary care management • SPT/RAST? • Go straight for amino-acid based formula (eg neocate). • Do not re-challenge after 4 weeks • Consider alternative diagnosis if not improving

10. Controversies in developing guideline • Extensively-hydrolysed or amino acid based? • Evidence is that 10% pts will not tolerate EHF and will need amino acid feed • If severe symptoms this rises to 50% • Agreed that EHF appropriate (& cheaper) for those managed in primary care, amino acid feeds for those requiring secondary care • Any role for partially hydrolysed formula?

11. Controversies in developing guideline • Re-challenge at 4 weeks or not? • Some suggest re-challenge, others say not, others say try EHF rather than amino acid feed • Agreed to re-challenge in primary care where more likely to be “temporary” feed issues which resolve with time rather than treatment. • Not to re-challenge in secondary care as more likely to have significant symptoms and re-challenge more harmful (& harder to sell to parents) • Role of SPT/RAST?

12. Discussion Thoughts and comments welcome